nutritional assessment in older persons

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NUTRITIONAL ASSESSMENT IN

OLDER PERSONS

Medical Faculty Brawijaya University

Malang

2011


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Definition of Aging

Miller (1994)

Aging is a process which converts a healthy adultinto a frail one accompanied with decrease in

physiological capacity of the body system, andexponentially increase in vulnerability to diseaseand death.

Aging is associated with gradual decline inperformance of organ systems,resulting in the lossof reserve capacity, leading to an increased chanceof death.


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Percentage of People 60 years and over in

selected Developing Country


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Life Expectancy at Birth

by World Region

Asia

Latin America and Caribbean Africa

Northern America Europe

1950-55 1970-75 1990-95 2010-15 2030-35

30

40

50

60

70

80

90


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Total Fertility Rates by

World region

TotalFertilityR

ate

Asia

Latin America and Caribbean Africa

Northern America Europe

1950-55 1970-75 1990-95 2010-15 2030-35


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OLD AGE

Fat mass

Muscle mass

Sarcopenia

Immunity

Cognitive function

Immobilization Gastrointestinal tract

impairment

Chronic diseases

Polypharmacy

Isolation / depression Education

Income

Body composition

Lean body mass

Fat mass

Total body water

Food intake

NUTRITIONAL

STATUS


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Malnutrition in the Elderly:

More common than you would think

2 - 10% free-living elderly populations 1

30 - 60% institutionalized elderly 1

40 - 85% nursing home residents 2

20 - 60 % home care patients2

(1) Vellas, B. et al, NNWS, 1999, Volume 1; (2) Nutr Screening Initiative


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Why the concern?

Malnourished elderly are:

2 times more likely to visit the doctor

3 times more likely to be hospitalized

Infection is the most common disorder

2 - 10 times more likely to die if malnourished

Diminished muscle strength

Poor healing Malnutrition is a greater threat than obesity


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Aging & MalnutritionWhy is this an issue?

Changes with aging: Physical

diminishing eye sight

poor dentition

taste changes

poor swallowing

Physiological

Metabolic

Psychosocial changes


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Aging and Energy Needs

With age, metabolism decreases

Body composition changes :Muscle mass decreases as adipose tissue increases

Results in 2% deceased metabolic rate per decade(Elmadfa and Meyer 2008)

Decreased physical activity less energy expenditure


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Nutrient Consumption

30% of elderly consume less kilocalories than

recommended (Lengyel et al 2008)

Decreased intake due to- Loss of appetite depression, dementia

- Medication-induced anorexia (American Dietetic Association 2005)

- Impaired taste perception

- Decreased density of taste buds (Winkler et al 1999)

- Higher thresholds for detection of tastes (Fukunaga et al 2005)- Loss of dentition

- Socioeconomic factors or functional disability effecting shopping and

meal preparation (American Dietetic Association 2005)


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Incidence of Malnutrition

Malnutrition is closely related to increased mortality

and morbidity :- Greater susceptibility to infection and longer hospital stays (Escott-

Stump 2008), increased risk of medical and surgical complications

(Baker and Wellman 2005), increased risk of pressure ulcers, hip

fractures, edema, cognitive changes (Escott-Stump 2008)

Incidence of malnutrition estimates range from 20-

78% (Bouillanne et al 2005)

Guigoz et al 2002 :- 2-10% of those living independently

- 30-60% of those hospitalized or institutionalized


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Food Guide Pyramid


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Aging and Micronutrient Needs

Vitamin and mineral needs remain unchanged with

age

Decreased food intake often results in deficient

intakes of micronutrients50% of older persons have lower than recommended

intakes of micronutrients (Escott-Stump, 2008)

80% of elderly persons have inadequate intakes of at

least on nutrient (Guigoz et al 2004)

Digestion, absorption, and synthesis of

micronutrients are decreased (Elmadfa and Meyer, 2008)


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Micronutrients of Concern

VITAMINS

B6, B12, folate

Vitamin E

Vitamin CVitamin D

Vitamin A

Thiamine

MINERALS

Selenium

Zinc

CalciumIron


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B6, B12 and Folate

Atrophic gastritis seen in ~ 30% of patients (Elmadfaet al 2008)

Reduced intrinsic factor production; reduced B12

absorption Clarke et al 2003 found

10-20% of subjects were at high risk for B12 and folate

deficiencies based on blood levels, serum homocysteine and

methylmalonic acid.

10% of subjects who were B12 deficient were also folate

deficient.

Buell et al 2007 found39% subjects deficient in folate, 18% subjects deficient in B6


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Deficiency Risks

High homocysteine levels resulting from B6, B12,

folate deficiencies linked to increased cardiovascular

disease risk and decreased mental agility (Marengoni

et al 2004) Folate deficiencies linked to increased dementia and

depression (DAnci et al 2004)

Excessive folate intake can mask B12 deficiency

Corrects hematological signs of deficiency but not neurologicalsigns.

Neurological signs include fatigue, malaise, vertigo, cognitive

impairment (Clarke et al 2003).


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Thiamine and other water-soluble

vitamins

Diuretics increases water-soluble vitamins losses as

urinary excretion is increased

Thiamine is especially at risk of becoming deficientdue to diuretics

Low dose thiamine supplement in the elderly on

diuretics may be useful in preventing deficiency

(Escott-Stump 2008)


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Vitamins A, E, and C

Commonly deficient Lengyel et al 2008 found 10%,

84%, 49% of subjects deficient respectively

Frail elderly are more likely to be deficient vitamin Eand A (Michelon et al 2006)

Centenarians are more likely to have high levels of

Vitamin E and A (American Dietetic Association 2005)

Needed for drug metabolism and detoxification


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Antioxidants

Vitamin C, E, beta-carotene needed in adequate

supply for decreasing oxidative damage to tissues

and cells including immune cells (Elmadfa and Meyer

2008) Balanced diet seems to be more effective than

supplementation for improved immune function

(Chandra 2004) but supplementation may be

effective (DAnci et al 2004)


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Calcium and Vitamin D

Bone mass decreases with age especially in women

resulting in osteoporosis

Direct health care cost of $12-18 billion each year just for

fractures (USDHHS 2004)

Absorption of calcium and vitamin D effected by age -receptor expression in duodenum decreases (Elmadfa andMeyer 2008)

Vitamin D synthesis decreases (MacLaughlin et al 1985)

Less time spent exposed to sunlight (Escott-Stump 2008) Vitamins A and K, and magnesium effect bone health as

well, but more research needed (American DieteticAssociation 2005)


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Selenium, Zinc, Iron

Depression in the elderly is associated with low

levels of selenium (Gosney et al 2008)

Low levels of selenium, zinc, and iron linked to

reduced cell-mediated immune response (Wintergerstet al 2007)

Low zinc intake associated with increased wounds

and severity (Tobon et al 2008)


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Nutrition ScreeningPurpose :

to quickly identify individuals nutritionally at-risk or

who are malnourished

Nutrition AssessmentPurpose :

to identify early signs of malnutrition and prevent it

from becoming a major co-factor in organ

dysfunction and morbidity and mortality


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What is Screening?

Separates those who are healthy from

those at high risk for the condition Tests should be non-invasive, inexpensive,

and have rapidly available results


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Screening Tools

MNA Short Form

Nutrition Screening Initiative

DETERMINE checklist

MUST (Malnutrition Universal Screening Tool)

Nutrition Risk Screening (NRS) (ESPEN)


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Developed in 1990 Validated for ages 65+

Simple, reliable, non-invasive,

& quick

Inexpensive Validated in hospital &

community setting

For screening & assessment

Guigoz et al., Nutr. Rev. 1996;54:S59-65Vellas B et al., J Am Geriatr Soc 2000;48:1300-1309cRubenstein LZ et al., J Gerontol 2001;56:M366-M372


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Validation of MNA

Nursing home, hospitalized & free living elderly

Sensitivity 96%

Specificity 98% Predictive value 97%

Inter-observer MNA- Kappa 0.51


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4 sections:

Anthropometrics

Diet questionnaire

Global assessment

lifestyle medications

mobility

Subjective assessment

self perception of health &nutrition


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Predictive ability of MNA

One-year Mortality

23.5 - 0%

Correlates with functional level

Good correlation with nutritional markers

Dietary intake, vit.D, folate, prealbumin


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Possible Problem Question to Answer YES

Disease I have an illness or condition that made me change the kind and /or amount of food I eat. 2

Eating Poorly I eat fewer than two meals per day. 3

I eat few fruits or vegetables, or milk products. 2

I have three or more drinks of beer, liquor or wine almost every day. 2

Tooth Loss/MouthPain

I have tooth or mouth problems that make it hard for me to eat. 2

Economic Hardship I don't always have enough money to buy the food I need. 4

Reduced Social Contac I eat alone most of the time. 1

Multiple Medications I take three or more different prescribed or over-the-counter drugs a day. 1

Involuntary Weight

Loss/Gain

Without wanting to, I have lost or gained 10 pounds in the last six months. 2

Needs Assistance In

Self Care

I am not always physically able to shop, cook and/or feed myself. 1

Elder Years > Age 80 Are you over 80 years old? 1

TOTAL

Nutrition Checklist for Older Adults"DETERMINE" Mnemonic

Name: _____________________ Today's Date: _________


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Scoring

0-2 Good! Recheck your nutritional score in 6 months. 3-5 You are at moderate nutritional risk.

See what can be done to improve your eating habits and

lifestyle. Your office on aging, senior nutrition program, senior

citizens center or health department can help. Recheck yournutritional score in 3 months.

6 or more

You are at high nutritional risk. Bring this checklist the next

time you see your doctor, dietitian or other qualified health or

social service professional. Talk with them about any problemsyou may have. Ask for help to improve your nutritional health.


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Nutritional Problem in Older Persons

Malnutrition

Obesity


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Protein Energy Malnutrition

(PEM)

Physiological causes of weight loss :

1. Anorexia of aging

the physiological decrease in appetite and food intakethat accompanies normal aging and which may result in

undesirable weight loss.

2. Sarcopenia (poverty of flash)

decline in muscle mass and strength .


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Non-physiological causes of weight loss

1. Poversty (saving dwindle and earning decrease)

2. Medical illness

3. Social isolation

4. Dementia

5. Dentures and oral health


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The management strategy employed would vary

according to the setting and thet could be tailored

for each individual patient.

Improve the reversible non-physiological factors Monitoring to ensure improvement in

nutritional parameters.

Management of Under-nutrition


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Summary

Changes associated with normal aging increasenutritional risk for older adults.

With advancing age, the risk of developing nutritionaldeficiencies increases.

Many older people are at at risk for deficient intakes ofsome essential nutrients (calories, calcium, vitamin B-6,magnesium and zinc).

Generally, nutritional problems are identified using

various biochemichal or anthropometric parameters, andimmunologic functions.


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nutritional assessment in older persons

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